Safety IQ Implementation: Establishing Protocols for Near-Miss Event Reporting
A near-miss event is a potential error that could have resulted in inappropriate medication use or patient harm but is discovered before the prescription reaches the patient. Pharmacy professionals excel at this type of ‘good catch.’ Safety IQ focuses not only on reviewing medication incidents or past harms, but also proactively reviewing near-miss events to prevent future harm. Near-miss event reporting and analysis is an opportunity to address gaps in existing pharmacy systems or procedures that could place patients at risk.
Not all near-miss events are valuable from an improvement or learning perspective and pharmacy professionals juggle many tasks throughout the workday. Establishing a protocol for near-miss event reporting can increase the efficiency and quality of your pharmacy’s reports. Pharmacy staff should consider:
- The potential impact on the patient: Would the patient be harmed if the medication reaches them?
- The recurring nature of the near-miss event: Does the same-near miss happen repeatedly? Perhaps there are areas of risk or weakness within the pharmacy process or system that should be reviewed and addressed.
- The potential shared learning for others: Could learning from a near-miss event benefit colleagues and patients in other pharmacies?
Pharmacy managers and staff should consider what near-miss events to report and then discuss how to change or enhance pharmacy processes to increase patient safety.
Webinar Recording: Community Pharmacy COVID-19 Vaccination Panel
On February 25, 2021, Pharmacists Manitoba hosted a Community Pharmacy COVID-19 Vaccination Panel in partnership with the Manitoba Government and the College of Pharmacists of Manitoba.
The webinar featured a presentation by:
- Dr. Joss Reimer, Medical Lead with the Provincial Vaccine Implementation Task Force
- Mr. Joe Funk, Deputy Team Lead – Distributed Channel Workstream
The presentation was followed by a live Q & A session with:
- Dr. Joss Reimer, Medical Lead with the Provincial Vaccine Implementation Task Force
- Mr. Joe Funk, Deputy Team Lead – Distributed Channel Workstream
- Inga Hossack, BSc., Policy Analyst, Communicable Disease Control
- Pawandeep Sidhu, Pharmacists Manitoba President
- Wendy Clark, President of the College of Pharmacists of Manitoba
You can access the recording through the CPhM COVID-19 Vaccine Resources and the News and Events pages.
Reminder: CPSM Standards of Practice for Prescribing Opioids and Benzodiazepines and Z-Drugs
The College of Physicians and Surgeons of Manitoba (CPSM) Standard of Practice for Prescribing Opioids and the Standard of Practice for Prescribing Benzodiazepines and Z-Drugs came into effect on September 30, 2018, and November 1, 2020, respectively.
Although the Standard of Practice for Prescribing Opioids and the Standard of Practice for Prescribing Benzodiazepines and Z-Drugs are CPSM Standards, pharmacy staff must be familiar with the Standards and resources in their entirety and must adhere to these principles when dispensing these medications to ensure patient safety. CPhM is currently working on a pharmacist companion document to these Standards.
CPhM is receiving calls from patients who were not informed of the changes to the prescribing and dispensing of their opioid, benzodiazepine and/or Z-drug medications and are confused why this occurred. Prescribers and pharmacists must work collaboratively and respectfully in providing safe and effective patient care. Both the pharmacist and prescriber should be educating patients on the requirements and importance of the new CPSM Standards and communicating how the Standards will affect the prescribing and dispensing of their opioid, benzodiazepine and/or Z-drug medications.
This is especially true when existing patients are affected by the new rules. Prescribers and pharmacists may need to discuss tapers as appropriate. Prescriptions may need to be altered or replaced and/or dispensing intervals adjusted to meet the new Standards. Documentation of these conversations with prescribers and patients is key.
CPSM has created a Frequently Asked Questions Document around the Standard of Practice for Prescribing Benzodiazepines & Z-Drugs to help patients understand the Standard’s recommendations. Specifically, the FAQs address common questions about:
- The risks and harms associated with benzodiazepines and Z-drugs;
- Reasons to attempt a taper and common experiences with tapering; and
- The new limitations around prescriptions and dispensing.
While this document is patient-focused, prescribers and pharmacists may find it beneficial to review as it can be a resource for patient care.
Save the Date – Annual General Meetings and Awards Presentation 2021
Please save the date for the 143rd Annual General Meeting of the College of Pharmacists of Manitoba (College). This year’s event will be held on May 8, 2021, in conjunction with the annual College Awards Presentation.
Plan to join your colleagues and friends, participate in the governance of the College, and celebrate excellence and leadership in pharmacy practice!
More information and a link to register will be shared in advance.
Summer Apprentice Notice
The College has an exciting summer job opportunity for a pharmacy student. We are looking for someone who is passionate about patient safety and is keen to contribute to exciting patient safety initiatives at the College. Join our skilled team of pharmacists and help further your career in pharmacy.
Please read the job posting for more information.
The deadline for applications has been extended to:
Friday, March 12, 2021, at 4:00 p.m.
Please submit your application to Lindsay Henderson, Executive Assistant, lhenderson@cphm.ca.
NABP Opens 2021 District V Study Grant Competition
The National Association of Boards of Pharmacy (NABP)/ American Association of Colleges of Pharmacy (AACP) (US) District V has announced that the study grant competition is now open for 2021. The College of Pharmacists of Manitoba (College) is a longstanding member of the District V of NABP/AACP.
District V of NABP/AACP will provide grant money, not to exceed $3,000 US per grant, to award two grants within the district to study topics which benefit students, pharmacy education, or pharmacy practice. Topics of interest to the Boards and Colleges in District V are suggested, but researchers will not be limited to these topics. Date of completion must be prior to the August 2022 District V NABP/AACP Annual Meeting in South Dakota, so that the results can be presented there.
The deadline for submissions is May 28, 2021. For more information, please see the study grant announcement: https://cphm.ca/wp-content/uploads/Temporary-Attachments/2021-Study-Grant-Announcement.pdf
Professional Development Opportunities:
Canadian Society of Hospital Pharmacists (CSHP)
National Virtual Conference 2021
March 20-27, 2021.
Register, here.